Boston Public Health Commissioner, Barbara Ferrer, says that while Boston has many Public Health needs, the three biggest challenges facing the city are reducing violence, making a positive health impact an explicit goal of every policy in every department, and using the new provisions of the Patient Protection and Affordable Care Act to get hospitals and other health-care providers to do more about prevention.
Although she probably would not object to adding obesity (with its tight connection to poor food, inadequate physical activity, and too much TV) and greater equity to the list, Commissioner Ferrer’s three challenges begin to frame a Public Health approach to livability. Safety, at home and on the street, is the prerequisite for nearly everything from personal wellbeing to neighborhood life to economic prosperity. Our health is not a separate phenomenon from everything else in our lives – our homes, neighborhoods, transportation methods, jobs, recreation, family and social life have a powerful effect on our well-being: policy makers dealing with any other those areas have to make health impact a visible consideration. No public agency or department should be allowed to narrow their focus in ways that externalize burdens and costs – every program has to include a broad range of goals. And we have to start forcing our health care system – the most technologically advance, most expensive, and least cost-effective in terms of population wellbeing of any industrialized nation in history – to pivot from prioritizing medicalized sickness treatment to helping keep people from getting sick in the first place.
Public Health is not just about living longer, but living better; not only about meeting basic needs, but the quality of people’s interactions; not just about individual health, but about population-societal well-being and equity. In this era of political polarization and cultural anxiety, Public Health provides powerful strategic insights for a variety of public issues. So it’s probably no accident that MassDOT’s latest advance towards transportation reform is titled the “Healthy Transportation Policy Directive.” It’s not just that Secretary Davey is using words required by the 2009 Transportation Reform Act, and it’s not that economics aren’t the most powerful underlying driver of politics. Just the opposite: it’s that he recognizes that for transportation – as for a huge number of other sectors – having access to basic daily needs such as jobs, healthcare, food and school is a catalyst for being healthy and is a critical part of the path to economic development with a high return on investment.
But too often, invoking health is a marketing ploy, not a programmatic or policy direction. Some of the misappropriation of the term is deliberate. Some of it comes from the confusion between Medicine’s focus (at least in our cultural image) on dramatic and quick results – the “magic pill” we all wish would solve our every problem – and Public Health’s focus on longer-term solutions and population wellness within its three themes of Prevent, Promote, Protect. Related to this is that most of us have little understanding of what Public Health encompasses. Rather than Medicine’s traditional focus on individualized treatment, Public Health is about maintaining wellness – prevention – and it focuses on interventions that increase resilience and reduce exposure to health risks for an entire population. Public health is not just about improving our overall health statistics, but also about the distribution of that improvement through every sector of society.
Public Health can be thought of as having three major components: Preventive Medicine, Standards Enforcement, and Primary Prevention, all in a context of reducing outcome disparities between subgroups. Preventive Medicine, such vaccinations and helping patients continue taking prescribed drugs, is what hospitals and other health service providers are beginning to do, but need to be forced to do more. Standards Enforcement, such as restaurant and housing code inspections, is one of the functions of government that we have to make sure declining budgets don’t cut into ineffectiveness. But Primary Prevention is the most fundamental, powerful, and difficult.
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